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Background-Current guidelines recommend intervention for symptomatic aortic stenosis, but the management of asymptomatic aortic stenosis remains controversial. As left ventricular global longitudinal strain (GLS) has been shown to predict cardiovascular outcome, we sought to find whether its use could guide the assessment of risk in these patients. Methods and Results-We prospectively followed 79 patients with severe asymptomatic aortic stenosis (39 men; mean age, 77 ± 12 years; aortic valve [AV] area index, 0.36 cm 2 /m 2 ). In addition to standard echocardiography, speckle strain was measured to assess GLS. Patients were followed for cardiac death and AV replacement driven by symptom development. A multivariable Cox regression was performed to identify associations with events. During 23 ± 20 months, 3 patients had cardiac death and 49 underwent AV replacement. Event-free survival was 72 ± 5% at 1 year, 50 ± 5% at 2 years, and 24 ± 5% at 4 years. Death and AV replacement were predicted by GLS (hazard ratio [HR] Methods Patient SelectionThe study population included patients with severe AS who were studied in our echocardiography laboratory from March 2004 to August 2010. Severe AS was defined as AV area <1 cm 2 or transaortic jet velocity >4 m/s. Patients were excluded if they had any additional hemodynamically significant valvular lesions, presented with symptoms (angina, dyspnea, or syncope) or LV ejection fraction (LVEF)<50%. After these exclusions, we enrolled 79 patients (39 men; 77 ± 12 years; AV area index, 0.36 cm 2 ). The protocol was approved by the institutional review board of the Cleveland Clinic. Clinical CharacteristicsClinical data were entered prospectively into an electronic health record, including age, sex, height, weight, history of coronary artery disease (previous positive coronary angiogram or stress test), history of diabetes mellitus (fasting blood glucose >126 mg/dL on 2 occasions or patients currently receiving treatment for diabetes mellitus), history of hypercholesterolemia (total cholesterol >190 mg/dL or patients receiving lipid lowering agents), history of hypertension (blood pressure ≥140/90 mm Hg or patients receiving antihypertensive drugs) were collected at baseline. The Society of Thoracic Surgeons (STS) Predicted Risk of Morbidity or Mortality (STS-PRMM) for AV procedures was calculated by entering patient data into an online STS risk calculator (http://riskcalc.sts.org/ STSWebRiskCalc273/). The STS-PRMM uses 24 variables of >50 total risk factors collected by algorithm to predict mortality for valve procedures. 17 EchocardiographyPatients underwent a standard echocardiogram performed by experienced echocardiographers, using commercially available ultrasound systems. The LV dimensions, wall thickness, and outflow tract diameter were measured according to the recommendations of the American Society of Echocardiography. 18 The degree of calcification of the AV was scored as: (1) no calcification; (2) mildly calcified (small isolated foci); (3) moderately calcified (multipl...

Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

Background Data comparing outcomes in heart failure ( HF ) across Asia are limited. We examined regional variation in mortality among patients with HF enrolled in the ASIAN ‐HF (Asian Sudden Cardiac Death in Heart Failure) registry with separate analyses for those with reduced ejection fraction ( EF ; <40%) versus preserved EF (≥50%). Methods and Results The ASIAN ‐ HF registry is a prospective longitudinal study. Participants with symptomatic HF were recruited from 46 secondary care centers in 3 Asian regions: South Asia (India), Southeast Asia (Thailand, Malaysia, Philippines, Indonesia, Singapore), and Northeast Asia (South Korea, Japan, Taiwan, Hong Kong, China). Overall, 6480 patients aged >18 years with symptomatic HF were recruited (mean age: 61.6±13.3 years; 27% women; 81% with HF and reduced r EF ). The primary outcome was 1‐year all‐cause mortality. Striking regional variations in baseline characteristics and outcomes were observed. Regardless of HF type, Southeast Asians had the highest burden of comorbidities, particularly diabetes mellitus and chronic kidney disease, despite being younger than Northeast Asian participants. One‐year, crude, all‐cause mortality for the whole population was 9.6%, higher in patients with HF and reduced EF (10.6%) than in those with HF and preserved EF (5.4%). One‐year, all‐cause mortality was significantly higher in Southeast Asian patients (13.0%), compared with South Asian (7.5%) and Northeast Asian patients (7.4%; P <0.001). Well‐known predictors of death accounted for only 44.2% of the variation in risk of mortality. Conclusions This first multinational prospective study shows that the outcomes in Asian patients with both HF and reduced or preserved EF are poor overall and worst in Southeast Asian patients. Region‐specific risk factors and gaps in guideline‐directed therapy should be addressed to potentially improve outcomes. Clinical Trial Registration URL : https://www.clinicaltrials.gov/ . Unique identifier: NCT 01633398.

ObjectivesThe traditional risk score (RAMA-EGAT) has been shown to be an accurate scoring system for predicting coronary artery disease (CAD). Arterial stiffness measured by the cardio–ankle vascular index (CAVI) is known to be a marker of atherosclerotic burden. A study was undertaken to determine whether CAVI improves the prediction of CAD beyond the RAMA-EGAT score.DesignCross-sectional study.PatientsPatients with a moderate to high risk for CAD by the RAMA-EGAT score were enrolled between November 2005 and March 2006. 64-slice multidetector CT coronary angiography was used to evaluate the coronary artery calcium score and coronary stenosis. Arterial stiffness was assessed by CAVI.Results1391 patients of median age 59 years (range 31–88) were enrolled in the study, 635 (45.7%) men and 756 (54.3%) women. Of the 1391 patients, 346 (24.87%) had coronary stenosis. There was a correlation between CAVI and the prevalence of coronary stenosis after adjusting for traditional CAD risk factors (OR 3.29). In addition, adding CAVI into the RAMA-EGAT score (modified RAMA-EGAT score) improved the prediction of CAD incidence, increasing C-statistics from 0.72 to 0.85 and resulting in a net reclassification improvement of 27.7% (p<0.0001).ConclusionCAVI is an independent risk predictor for CAD. The addition of CAVI to the RAMA-EGAT score significantly improves the diagnostic yield of CAD.

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BackgroundThe aim of this study was to compare left ventricular (LV) remodeling using myocardial strain between patients with severe aortic stenosis (AS) treated with transcatheter aortic valve replacement (TAVR) with and without prosthesis‐patient mismatch (PPM).Methods and ResultsIn a retrospective study, speckle‐tracking echocardiography was used to measure global longitudinal strain (GLS) and strain rate (GLSR), circumferential strain, and rotation before and at mid‐term follow‐up post‐TAVR. Moderate and severe PPM were defined as an effective orifice area ≤0.85 and <0.65 cm2/m2, respectively. A total of 102 patients (median age, 83 years [77–88]) with severe AS were included. At 6±3 months post‐TAVR, moderate and severe PPM were found in 32 (31%) and 9 (9%) patients. Patients without PPM had a significant regression in LV mass (from 134±41 to 119±38 g/m2; P=0.001) at follow‐up whereas those with PPM did not. There was a significant improvement in LV GLS (−12.8±4.0 to −14.3±4.3%; P=0.01), GLSR (−0.61±0.20 to −0.73±0.25 second−1; P<0.001), and early diastolic strain rate (0.52±0.20 to 0.64±0.20 second−1; P<0.001) in patients without PPM, but not in those with PPM. After adjustment for pre‐TAVR ejection fraction and post‐TAVR aortic regurgitation, patients without PPM had greater improvement in LV longitudinal strain parameters compared to those with PPM. After a median follow‐up of 46.1 months (interquartile range, 35.4–60.8), there was no difference in survival between patients with and without PPM.Conclusions TAVR was associated with an incidence of PPM of 40%. Greater reverse LV remodeling using myocardial strain was evident in patients without PPM compared to PPM. Presence of PPM was not associated with mortality.